Your Health Checkup: Drugs and Daily Activity

“Your Health Checkup” is our online column by Dr. Douglas Zipes, an internationally acclaimed cardiologist, professor, author, inventor, and authority on pacing and electrophysiology. Dr. Zipes is also a contributor to The Saturday Evening Post print magazine. Subscribe to receive thoughtful articles, new fiction, health and wellness advice, and gems from our archive. 

Order Dr. Zipes’ new book, Bear’s Promise, and check out his website www.dougzipes.us.

Yesterday morning while exercising as usual, I inflamed an old biceps tendonitis that triggered pain whenever I moved my arm. I needed treatment with a nonsteroidal anti-inflammatory drug (NSAID).

While researching which drug to take, I came across an interesting article stating that administering NSAIDs during the daily activity period, i.e., in the morning for most people, resulted in better pain relief and healing than taking the NSAID in the evening prior to retiring.

The reason appears to be based on the body’s circadian rhythm; that is, the cyclical 24-hour period of human biological activity.

The mediators of most wound healing and connective tissue formation occur during the resting phase of the day, while pain and inflammation occur during the active period of the day. It follows that one would want the NSAID impact to occur during the period of pain and inflammation and not during the wound healing phase, hence the recommendation for taking the drug in the morning.

The opposite is true for blood pressure control. As I have written previously, the time to take blood pressure medication is in the evening, not the morning. Nighttime blood pressure is a stronger risk predictor of cardiovascular disease than is daytime blood pressure, and blood pressure control at night works better than control in the morning.

So, take NSAIDs in the morning and blood pressure medicines in the evening.

But here’s a drug you probably should avoid, if possible: azithromycin.

Azithromycin (AZ), an antibiotic in the same class as erythromycin, is one of the most commonly prescribed antibiotics in the U.S. despite an increased risk of cardiovascular death noted in some studies, perhaps related to changes in heart rhythm A recent study of almost 8 million antibiotic exposures (22 percent AZ; 78 percent amoxicillin) from January 1, 1998 to December 31, 2014, in patients with a mean age 51 years, and 62 percent women, found that AZ was associated with about a twofold increased risk of death during the first five days of exposure compared with amoxicillin. I would recommend that AZ be used with caution, particularly in patients who might be at increased risk, such as those with underlying heart disease, electrolyte abnormalities, or those taking other drugs that might affect the heart rhythm in a similar fashion.

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Your Health Checkup: Medication Mishaps and the Balance Between Benefit and Risk

“Your Health Checkup” is our online column by Dr. Douglas Zipes, an internationally acclaimed cardiologist, professor, author, inventor, and authority on pacing and electrophysiology. Dr. Zipes is also a contributor to The Saturday Evening Post print magazine. Subscribe to receive thoughtful articles, new fiction, health and wellness advice, and gems from our archive. 

Order Dr. Zipes’ new book, Bear’s Promise, and check out his website www.dougzipes.us.

One of the first guiding precepts I learned as a young physician was from Hippocrates, who taught “Primum non nocere,” or “Above all, do no harm.” The Latin phrase reminds all doctors to consider the possible adverse consequences of a medication or a procedure since all therapeutic interventions confer a risk as well as a benefit, and the balance must be assessed in a given patient.

Problems can result when patients make medical decisions for themselves or loved ones and fail to consider all the pros can cons. For example, self-medication can be risky, such as the use of dietary supplements. As a society we spend $35 billion a year on dietary supplements, the vast majority of which have no proven benefit, yet we challenge established lifesaving advances such as the use of vaccinations or water fluoridation.

A major problem with dietary supplements is that companies manufacturing them are not required to establish safety before marketing. They are only required to report serious adverse events that are monitored by the FDA, who then must hold the company to account. Experts propose a very short list of benefits, including ginger for nausea, peppermint for upset stomach, melatonin for sleep disruption, fish oil for cardiovascular health, folic acid for pregnant women, and vitamin B12 for vegans or the elderly with poor absorption.

There can be notable harm with some dietary supplements as well as with some commonly prescribed medications. I have written about nonsteroidal anti-inflammatory drugs such as ibuprofen, celecoxib, and naproxen, and recommended acetaminophen as a substitute. But the latter, in excessive doses, can also be a problem by causing liver disease.

Polypharmacy – taking multiple drugs at the same time –  creates the potential for harmful drug-drug interactions. Almost half of older adults take five or more medications, and one in five of these drugs may be inappropriate, often leading to hospitalization for an adverse drug reaction.

Examples of some common drugs that can cause problems include the following:

• Proton pump inhibitors (e.g. Prilosec, Prevacid, Nexium) are generally well tolerated but can cause a variety of side effects such as electrolyte imbalance, osteoporosis, kidney disease, pneumonia, and GI infections when taken long term, and should be avoided unless medically necessary.
• Excessive prescription of antibiotics, particularly for viral infections such as the flu or common cold, has contributed to the development of antibiotic-resistant bacteria. Almost a third of the estimated 154 million antibiotic prescriptions written annually are not necessary. In addition, some antibiotics such as fluoroquinolones (e.g., Cipro, Levaquin) are potentially dangerous because they can increase the risk of tendonitis, tendon tears, and weakened walls of some blood vessels.
• Antimuscarinics such as Detrol or Vesicare provide very little benefit in treating overactive bladders and can cause dry mouth, constipation, blurred vision, somnolence, and dizziness. Long-term use has been associated with cognitive impairment.
• Nonbenzodiazepines such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata) are sedative hypnotics taken by more than 5-10 percent of U.S. adults to treat anxiety, mood disorders, depression, and insomnia, as well as seizures. Misuse can result in overdoses and death and is often associated with opioid misuse. Benzodiazepines such as Xanax, Valium, and Ativan can also cause problems such as fatigue, memory problems, dizziness, and loss of balance.

These drugs offer some examples of potential problems that can occur with medication misuse. My advice is: read labels and talk to the pharmacist or your physician to be sure you are not over medicating, even with apparently harmless medicines like multivitamins. Remember, there are risks to self-medication, so take charge of your own health and avoid medication mishaps. Put all your medications — including dietary supplements — in a bag and take them to your health provider or pharmacist. Go through them one at a time with an expert to be sure to keep what is relevant and important, and toss the rest.

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Managing Pain Without Pills

During the summer of 2017, my dear friend Colin Hickey needed to undergo surgery. He had managed to tear the labrum of each hip (a cartilage ring around the hip socket), due to a combination of his active lifestyle of hiking, playing tennis, and dancing, plus a structural deformity. The surgeon needed to fix both sides, so he would operate on one side first and then do the other a couple of months later.

This sort of surgery is difficult to describe in terms of its “seriousness.” On the one hand, it’s minimally invasive. The surgeon is able to do the work with only very small incisions, so the outward appearance is of a fairly minor surgery. Once inside, however, he would have to repair the torn cartilage and carve down some excess bone to prevent the sort of friction that caused the tear in the first place. This explains why people who undergo this surgery have months of physical therapy and recovery, after weeks of extremely limited mobility.

After his first surgery, I visited Colin at his apartment, and since I had undergone multiple surgeries two years earlier after a motorcycle accident, we swapped “war stories.” He was in pretty rough shape, able to move only very little, and was confined to his bed for most of the day. He looked pained but also completely alert. I asked him about his pain and meds.

“Yeah, they gave me a bottle of pills, but I don’t want ’em,” he replied. He knew of my struggle with painkillers — when I went through months of excruciating suffering caused by opioid dependence  — and he looked at me sympathetically. “Obviously I know the risks; but I also just don’t think I need them. It hurts, and it’ll hurt for a while. But the first days were the worst, and I made it through. So I don’t think they’re necessary.”

As usual with Colin, who is one of the most focused, thoughtful, straight-up toughest people I know, I was impressed. “So you didn’t take any of the pills? At all?”

“Not a one,” he replied.

Colin has always been something of an ascetic. He doesn’t need stuff, and he isn’t a huge fan of medicine. And while he would have, I think, taken the pills if he really thought he needed them, he just wasn’t afraid of some pain, and he was willing to be uncomfortable and work hard.

I’ve always admired him for his dedication to a philosophically rigorous life, but I admired him even more after that day. There wouldn’t have been anything wrong with his taking the pills, but he didn’t need them. And instead of using them anyway, to drive his pain down from manageable to zero, he just stuck it out. When he went in for the second surgery some weeks later, he told his surgeon that he hadn’t used any of the pills, so he didn’t need a new prescription.

And he was right. When the summer was over, and both hips had been fixed, he was pushing his way through physical therapy and still had an untouched bottle of 60 Percocet.

Nothing about my admiration for Colin should indicate that I think all torn labrum surgeries should be ­performed without prescribing opioids for recovery. If you have had that surgery and you took some of the pills, I get it; I probably would have too. What I love about Colin’s story, rather, is that it highlights the degree to which some pain can simply be dealt with. Not all of it needs to be, but some of it can be.

“Yeah, they gave me a bottle of pills, but I don’t want ’em,” he replied.

Life hurts — quite a lot for some of us — but not all of those pains require pharmacological intervention. And importantly, our expectations can really affect how reasonable that suggestion seems. Part of why Colin was able to make it through that summer, I think, is because he doesn’t expect life to be pain-free, and he’s willing to put up with quite a lot. Perhaps more than should be expected of any of us. But it’s important to reflect on what we can do in order to think carefully about what we should do.

After my accident in 2015, trauma caught me by surprise, and when I found myself in hospitals for weeks, on morphine and fentanyl drips, popping oxycodone, I hadn’t prepared myself at all. It was all new and terrifying. I had one goal: avoid the pain. And only in retrospect can I realize that I carried that goal much too far forward into my recovery.

I wish someone had prepared me for the pain — told me that I would hurt and that it would be scary, but that I didn’t have to let elimination of pain become my sole priority. In short, I wish I had been mentally ready to balance the need for pain relief against the risks and costs of medication. This leads me to think that one of our major goals for rethinking how we deal with pain is not a goal for physicians; it’s a goal for the rest of us.

In many places around the world, but especially in America, we live in a “pill for every pain” culture. You have a headache? There’s a pill for that. Sprained your ankle? Pill for that. Ongoing back pain? Yup, you guessed it. Our over-the-counter medications already capitalize on this culture, selling us acet­aminophen, ibuprofen, and aspirin by the buckets. It’s no surprise, then, that prescription pharmaceutical companies jumped on board as well. The basic strategy behind Purdue’s marketing campaign in the 1990s and early 2000s was that OxyContin was effective (stronger than morphine, and lasts 12 hours!) and safe (less than 1 percent of patients develop an addiction!). So why restrict its use to cancer or palliative care? OxyContin is the pill for moderate to severe pain — the pill, that is, for nearly every pain.

The unfortunate fact, however, is that medications have side effects. The effects of opioids can be particularly devastating, but that certainly doesn’t make it the case that all other painkillers are perfectly safe. Acetaminophen must be carefully limited in dosing to avoid causing liver damage, NSAIDs like ibuprofen and celecoxib raise one’s risk of heart attack and stroke.

This consideration of trade-offs is especially difficult for treating chronic pain. As we now know, opioids should not be considered first-line treatment for chronic pain, as they are risky and may well be no more effective than non-opioid therapies. However, most physicians will also warn patients that a lifetime of any pain medication can be dangerous, given the side effects listed above. Determining how to proceed is truly difficult. Sometimes there are alternative interventions that can be considered, such as injections, nerve blocks, or surgery. And sometimes it is completely unclear what will be best for a particular patient.

Not all treatments for pain involve a pill (or some other medical procedure). A truly surprising amount of scientific data supports what we might think of as “lifestyle” therapies, or as some people call it: self-care.

There are many such strategies, supported by varying degrees of scientific evidence, and more research is being conducted all the time. Looking at just some of the most common suggestions: Exercise, yoga, and massage have all been shown to be beneficial for dealing with pain. And really, this shouldn’t be all that surprising. After all, doing these things amounts to taking care of one’s body, which can strengthen and heal weak and damaged tissue.

I wish someone had prepared for the pain — told me that I would hurt and that it would be scary, but that I didn’t have to let elimination of pain become my sole priority.

Additionally, cognitive-behavioral therapy (CBT) — a form of psychotherapy that focuses on altering unhelpful cognitive patterns and behavior — has been shown to be effective for treating certain forms of chronic pain. Despite this evidence base, however, many people find such a suggestion offensive: “What? So you think this is all in my head? You think my pain isn’t real?”

That pain can be treated with CBT, however, implies nothing of the sort. Chronic pain is often what’s called “maladaptive pain,” which means it no longer signals tissue damage or injury. Whereas acute pain serves as an alert that one’s body is at risk, that same pain can transition into chronic pain that no longer serves that function.

It’s maladaptive — rather than adaptive — pain that causes suffering but which plays no productive health role. The evidence that CBT can successfully treat chronic pain suggests that therapy can help the brain and nervous system to correct this dysfunction. By pursuing psychological health, one can simultaneously promote pain relief.

Acupuncture has also been shown to be effective in treating chronic pain. And research is being conducted into all sorts of lifestyle interventions, ranging from mindfulness meditation to qigong and tai chi. In short, the evidence is mounting that changing one’s lifestyle can constitute genuine pain therapy. None of them is a magic bullet (sadly, we don’t have one of those), but they are genuine treatments.

Look, it’s certainly not the case that self-care is magic and will replace our need for powerful opioid medications. Some pain is devastating and life-limiting, and sometimes that pain responds well to opioids. I am most certainly not recommending that we all just get up after an injury and “rub some dirt in it.” That’s not the answer, and not my suggestion.

But we can be part of an important culture change. We can stop demanding from our doctors a pill for every pain, and we can try to take seriously the nonpharmacological treatments they suggest. We can ask whether 60 pills is really necessary, or whether just a few might do.

In short, each one of us can make a difference. Not by trying to eliminate opioids from pain medicine but by formulating an attitude and a set of expectations that help our doctors use those powerful tools responsibly.

We all need to foster a different relationship with pain and develop a different understanding of medicine — what it does and doesn’t owe us, and what we should expect from our doctors. We also need to understand addiction and expand our circle of empathy, demanding that our elected officials do the same.

Medicine can be improved and public health interventions can be introduced, but they won’t be unless we demand them.

From In Pain: A Bioethicist’s Personal Struggle with Opioids by Travis Rieder. Copyright © 2019 by Travis Rieder. Reprinted by permission of Harper, an imprint of HarperCollins Publishers

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